Smug About Suffering

Review of Cracked: Why Psychiatry is Doing More Harm than Good, by James Davies, and Our Necessary Shadow: The Nature and Meaning of Psychiatry, by Tom Burns.

Our understanding of the brain is primitive at best, and our treatments for mental illnesses are appalling. They are not very effective, cost a lot and carry innumerable side effects. That said, recent progress in understanding the brain and treating mental illness is dazzling. It’s a bit like space exploration: we know a lot more than before we managed to blast off, but our increased knowledge has underscored how much there is to learn. As someone who suffers from depression, I’m grateful that I live now and not 50 years ago, when the treatments that have helped me were unavailable. I hope, however, that people with my psychological profile 50 years hence will look back at my treatment and shudder at the idea that anyone had to endure such crude interventions.

Like many people with my condition, I have benefited from both talk therapy and medication. The tension between a brain-based model and a talk-based one is often posed as a modern problem, but it is at least 2,500 years old. Hippocrates wrote that, “it is the brain which makes us mad or delirious, inspired us with dread and fear, whether by night or by day, brings sleeplessness, inopportune mistakes, aimless anxieties, absent-mindedness, and acts that are contrary to habit.” He proposed treatment with oral remedies. Socrates and Plato claimed that such disorders were the province of philosophers; Plato’s division of the psyche into the rational, libidinal and spiritual is uncannily like Freud’s. Hippocrates is, in effect, the great-grandfather of Prozac; Plato, of psychodynamic therapy.

It became fashionable in the 1990s to disparage psychoanalysis and Freud in particular. We had come to understand that mental illnesses were brain diseases and we no longer needed the mythologising mumbo-jumbo of the Oedipus complex and object relations. While the Freudian paradigm needed revision, as any point of view does over time, it was a mistake to jettison its insights. Understanding the brain should never preclude understanding the complexity of human thought. Once the psychoanalytic baby was thrown away with the bathwater, the attack on biological psychiatry kicked into full gear. But the brain and the self are far too complicated to be understood through any single vocabulary. It turns out that “know thyself” is the trickiest instruction ever given.

Into this fray come two new books: the intelligent if sometimes earnest Our Necessary Shadow, by Tom Burns, and the incoherent, sensationalistic Cracked, by James Davies. Burns’s goal is to explain what psychiatry is and how it arrived at its current state. Displaying the dignified passion of someone trying to construct a better world, Burns shows us psychiatry’s triumphs and is frank about its pitfalls.

Davies’s goal is to rip apart psychiatry by exposing it as institutionalised charlatanism. Among his many assertions are the claims that antidepressants are hardly better than placebos; that most people with schizophrenia are better off not taking antipsychotics; that lithium is bad for people with bipolar disorder; that psychiatry’s medicalising of normal states fuels the despair it professes to address; and that the use of medication in psychiatry is owed almost entirely to the rapaciousness of the pharmaceutical industry. He avers that our inability to map mental illnesses in the brain means that we have no basis for treating them.

Davies is obsessed with his own research process and has a curious preoccupation with the geographical location at which he arrived at each of his insights. He poses as a sort of Miss Marple enthralled by finding patterns in the evidence he accrues — but he lacks her winning self-effacement. He sets up straw men and knocks them down with glee. It’s a shame that his book is so obnoxious and riddled with misinformation, because it approaches profound ontological questions about self-identity, and the fixity of the human mind.

Davies often addresses the reader directly: “If things are ever to be put right, then what is required above all are people, just like you, understanding and spreading the word…” Sometimes, this assumption of complicity escalates into melodrama even as it descends into cliché: “Before I address this important question, it’s only fair I first warn you: if you suffer from high blood pressure, you should probably consult your physician before turning the page.”

If he is annoying in imposing his values on the reader, he is equally so in dramatising his conversations: “Trying not to look shocked, I continued”; and elsewhere, “trying to sound unfazed, I asked Frances to clarify.” He keep up the attitude of the chippy, benighted underdog. Of his visit to the United States Senate office building, he writes: “While sitting there it became clear to me: it was hopeless to pretend I fitted in. My suit was too shabby, my hair too long, and I didn’t have a Blackberry.” When he is interviewing someone he wishes to disparage, the person’s bearing comes under critique; when he meets someone he admires, quite the opposite. When he references a craven invitation from a pharmaceutical company to a doctor, we get: “They would make their way to a luxurious hotel… where a Wyeth attendant with a dazzling smile would greet them.” The pharmaceutical industry’s exploitation of dazzling smiles seems hardly significant to its degeneracy.

Davies’s stylistic shortcomings would be less irksome if most of his points hadn’t been made before, most notably in Irving Kirsch’s The Emperor’s New Drugs, Robert Whitaker’s Anatomy of an Epidemic, and Daniel Carlat’s Unhinged. Davies correctly suggests that many people are receiving treatment who do not need it, but neglects to note that far more people are not receiving treatment from which they might benefit. He takes particular umbrage at the “chemical imbalance” theory that people with compromised mental health have a neurotransmitter deficit. This theory has been out of circulation for a decade, and Davies never acknowledges more recent evidence that antidepressants have been associated with growth of neurons. The fact that increasing serotonin in the synapses helps to alleviate depression does not indicate that depression is caused by low serotonin levels — any more than, as Burns puts it, the fact that a headache remits with aspirin means that it was caused by a deficit of aspirin. Davies quotes Carlat on the perils of psychopharmacology without acknowledging that Carlet has obgserved “an unequivocal if perplexing truth about psychiatric drugs — on the whole, they work.”

Davie relies heavily on Kirsch’s work showing that placebos can be as effective as medication in treating depression, but Kirsch’s conclusions have been repeatedly challenged. While Davies rightly lambastes the pharmaceutical companies for cherry-picking which studies to publish, he shows no qualm about doing his own cherry-picking. Erick Turner’s analysis of more extensive data than Kirsch’ indicated that placebos are highly effective but that antidepressants are consistently more effective. Konstantinos Fontoulakis has shown that Kirsch miscalculated the mean drug-placebo difference. Relapse studies show that while many people have a robust initial placebo response, predicated in part on the close attention being paid to them in a clinical trial, 41 percent will relapse quickly, while only 18 percent of those on medication will do so.

Davies writes: “Unless our sciences can test whether what we agree on is objectively the case, agreement counts for nothing from a scientific standpoint. So even if psychiatrists reach high diagnostic agreement at some future point, this would not prove that the mental disorders with which they diagnose patients actually exist as valid disease entities.” It is true that psychiatry relies primarily on patient reports of how they are feeling rather than on biomarkers, and there is a strong move afoot at the U.S. National Institute of Mental Health that hopes to address this, in the form of the Research Domain Criteria project. What’s more, Helen Mayberg’s recent work, just published in Nature, has identified a biomarker that distinguishes people who will respond best to medication (above-average activity in the right interior insula) from those who will do better in talk therapy (below-average activity in the same region). We do not understand the biology of mental illness and we do not really understand how medications act against it. But neither do we understand fully the etiology of most cancers, and we are only now reclassifying them by genotype rather than by the organ or system in which they originate.

Psychiatry is deeply flawed, but flawed does not mean worthless. Pharmaceutical companies are in hot pursuit of profits and have used money to influence doctors, creating a web of conflicting loyalties that often biases treatment. Yet they are also held to rigorous standards, and the people who develop drugs and bring them to market — which costs too much to happen outside of industry — are often motivated in part by the hope of alleviating suffering. “[W]henever someone ostensibly benefits from a psychiatric prescription, the pharmaceutical industry and many within psychiatry benefit too,” Davies writes accusingly. But when a doctor performs a heart transplant, he gets paid, and so does the hospital, and pharmaceutical companies profit from the immunosuppressant drugs that are used by transplant recipients. The fact that there’s money to be made in the exchange of commodities and services does not invalidate the source of profit.

Burns, in stark contrast to Davies’s pessimism, asserts that there has been a “stepchange in psychiatry’s ability to alleviate distress and to cure what were once awful illnesses.” Burns writes persuasively of how “the sick role… confers protection and, in exchange for accepting the need to comply with treatment, offers care, sympathy and a variable exemption from social demands.” He observes the urgency of these questions, too. “The luxury we do not have is to declare ourselves unsatisfied with current thinking and to tell our patients to go away and come back some years hence when we have the answers.”

Davies’s most vigorous criticism is that psychiatry, “by progressively lowering the bar for what counts as mental disorder, has recast many natural responses to the problems of living as mental disorders requiring psychiatric treatment.” I’d argue almost the opposite: that a century ago, you would have accomplished very little by seeking a diagnosis for your mental woes; all that could be said that such pain was part of the human condition. Nowadays, acknowledging your inner turmoil gives you access to technologies that may allay it. Because diagnosis is now useful, there is more of it. And it is worth noting that while Davies attacks the expansion of the Diagnostic and Statistical Manual of Mental Disorders, the International Classification of Diseases is expanding at a comparable rate, with new physical illnesses constantly being delineated. Burns agrees with Davies that “our decision to consult a doctor depends on what we expect to feel, what we consider ‘normal,’ and what we believe can be done about it. These have changed out of all recognition.” For Davies, these changes constitute a trap; for Burns, they offer emancipation.

“One of the most powerful myths embraced by the psychiatric establishment,” according to Davies, is that “psychiatric drugs are capable of ‘curing’ us and are therefore distinct from recreational drugs that merely alter our state of mind.” This is another one of Davies’s straw men. No one has claimed that such pills “cure” mental illness; they only treat its symptoms. But neither does ibuprofen cure arthritis, nor tamoxifen cure breast cancer.

Davies’s most dubious choice is to impose moral language on the conversation. When he argues that “experiences of sadness, anxiety or unhappiness were often listed as symptoms of underlying disorders, rather than seen as natural and normal human reactions to certain life conditions that needed to be changed,” he seems to be on a moral quest to lionise what is “natural” — and therefore should not be changed. I’d like to wish upon Davies a month of acute psychosis or major depression and then see how he feels about lessons learned, and check whether this pompous psychic Marxism continues to appeal to him. His smug view of human suffering conflates the fact that suffering can be ennobling with the supposition that people should do more of it. When we medicate away depressive illness or anxiety, what we are doing is allowing people to be unhappy about things that matter — about damaged relationships, professional disappointments, global warming — instead of being in a state of free-floating despair or emotional devitalisation with no purpose and no focus.

Life is short, and if we can help people not to lose untold years to unproductive anguish then we should do so. It is natural to have one’s teeth fall out, and unnatural to brush them, but we do not militate against toothpaste. It is natural to end a hard day’s work with water, but we don’t seek to ban the moderate consumption of distilled spirits that helps some people relax. Without medication, I could make a lot of changes to diminish my psychopathology. I could write less, and about less personal subjects. I could skip fatherhood and marriage. I could curtail my life and achieve some moderation of the symptoms that have been so paralysing. But is that a reasonable choice to make? Not to me. “It was hubris for medicine to try to manage realms of life it was never designed to treat,” Davies writes. But designed by whom? Burns champions “respect for individual choice, even foolish choices.”

The drugs and interventions that we have are not easy to tolerate, but neuroleptics have transformed the experience of people with schizophrenia, and antidepressants clearly help people with major depression. Davies’s book will likely influence at least a few people away from treatment that could save them. Some of these people may commit suicide and others will live in dire pain. His arrogant, ill-informed attempt to discredit psychiatry leaves him with blood on his hands.